Overview of Inflammatory Bowl Disease - Bernadino Flashcards
What are the two types of Inflammatory Bowel Disease?
- Ulcerative Colitis
- mucosal disease
- rectum and extends continuous
- Crohn’s Disease
- Transmural
- Any distribution
- Types
- obstructive/fibrostenotic
- penetrating/fistulizing
What age is the peak incidence of IBD?
15-25 years old
(second peak may be observed in 70’s)
What are the symptoms of IBD?
(ulcerative colitis vs. crohn’s)
-
Ulcerative Colitis
- Bloody mucoid diarrhea
- Tenesmus (frequent BM’s)
- Jaundice (with sclerosing cholangitis)
- Arthralgias, uveitis, and skin ulcers
- Fecal incontinence
-
Crohn’s Disease
- Nonbloody diarrhea
- Abdominal pain
- Weight loss/anorexia
- Perianal abscess, fistula, chronic fissure
- Growth failure (children)
What infections mimic IBD?
- Bacteria:
- Shigella
- EHEC, EIEC
- Campylobacter jejuni,
- Salmonella
- Yersinia enterocolitica
- MTB
- C. difficile,
- Vibrio parahaemolyticus,
- Chlamydia
- Parasites: Entamoeba histolytica, Trichinella
- Viruses: Cytomegalovirus
- Proctitis: Neisseria gonorrhoeae, HSV, Chlamydia trachomatis, Treponema pallidum, Cytomegalovirus
What is the clinical course of Ulcerative colitis?
- Chronic, relapsing disease
- Hematochezia, tenesmus, pain
- Rectum with confluent proximal extension.
- Colectomy rate: 30% over 30 years
- Colon cancer: 18% over 30 years
- Primary Sclerosing Cholangitis 4%
What does the microscopic mucosal inflammation look like in UC?
- Acute / chronic mucosal inflammation
- Cryptitis / crypt abscesses
What parts of the GI tract does Crohn’s Disease involve?
- A pan-enteric transmural inflammatory disease
- Mouth to anus
- Usually spares rectum
- 70% involve the terminal ileum
- Skip lesions
- Perianal involvement
- Transmural complications – Fistulae, abscess, strictures
How helpful is surgery in IBD?
- UC = surgery is curative
- Crohn’s = surgery treats complications
- non-curative
- 80% require surgery by 15 years
- will have repeat surgeries after first one
Which type of IBD often has granulomas seen in the microscopic biopsy?
Crohn’s Disease
What serologies may be helpful in “indeterminant colitis”?
- Crohn’s
- ASCA - anti-Saccharomyces cerevisiae antibodies
- Ulcerative colitis
- pANCA - perinuclear antineutrophil cytoplasmic antibodies
What are common IBD extraintestinal manifestations?
-
Musculoskeletal:
- Arthritis, ankylosing spondylitis, osteoporosis, sacroilitis
-
Skin and mouth:
- erythema nodosum, pyoderma gangrenosum, aphthous ulcers, vitiligo, psoriasis, amyloidosis.
- Ocular:
- Uveitis, iritis, episcleritis.
- Hepatobiliary:
- Primary sclerosing cholangitis, cholangiocarcinoma, hepatitis, pericholangitis, gallstones (ileal Crohn’s disease)
- Pancreatitis
- Thyroiditis
- Pulmonary: Bronchiolitis
What are the complications of Ulcerative Colitis?
-
Toxic megacolon
- common complications
- leads to perforation, sepsis, and SIRS
- Hemorrhage
- Stricture
- Hypercoagulability
- Colon cancer
- PSC
What are the complications of Crohn’s Disease?
- Abscess
- Perforation (infrequent)
- Obstruction, SBO
- Hypercoagulability
- Colon cancer
- Hemorrhage
- Ileal disease or resection (> 100cm)
- Bile salt diarrhea
- Gallstones
- Vit B12 deficiency
- Oxylate stones
What is the risk of Colorectal Cancer in IBD?
- Increased risk (5%)
- 1-3% at 10 yrs
- 18% at 30 years with pancolitis
- Flat or depressed adenomas—fields of dysplasia.
- Increased risk with:
- Disease proximal to splenic flexure
- > 8 years duration; young age at diagnosis
- Primary sclerosing cholangitis
- Family history of CRC
- Pseudopolyps at colonoscopy
- 5-ASA treatment is protective
What is the proposed pathogenesis of IBD?
- Compromised gut mucosal barrier
- Over activity of proinflammatory immunity (Th1 responses)
- Decreased suppressor T cells
- Unregulated Th1 responses (loss of tolerance)
- Genetic susceptibility conferred by mutations at distinct chromosomal loci, NOD2
- Microbial antigens can lead to self-perpetuating inflammation in genetically susceptible hosts
What are the proposed environmental influences that contribute to the pathogenesis of IBD?
- Clean Kid hypothesis
- IBD more common in cold climates
- IBD more common in industrialized areas
- Crohn’s > UC are smokers; are s/p appendectomy
- Active disease increases risk to fetus and mother in pregnancy
What are the current expectations/treatment goals for IBD therapy?
- Induce clinical remission
- Maintain clinical remission
- Improve patient quality of life
- Heal mucosa – endoscopic remission
- Decrease hospitalization/surgery and overall costs
- Minimize disease-related and therapy-related complications
What re the IBD therapeutic approaches for Induction Treatment?
- 5-ASA (mild disease)
- Sulfasalazine, mesalamine
- balsalazide
- Steroids
- Prednisone, budesonide
- Biologics – Infliximab
- Cyclosporine (transition to surgery)
- Surgery
- UC – cure
- Crohn’s – to treat complications
What re the IBD therapeutic approaches for Maintenance Treatment?
- 5-ASA
- Mild severity
- UC>>Crohn’s
- Immunomodulators
- Azathioprine
- 6 Mercaptopurine
- Methotrexate
- Biologics – Infliximab
What choice of drugs are used to treat IBD in the small bowel and right colon?
- Mesalamine → Pentasa
- Steroid → Budesonide
How do you treat IBD in pregnant patients?
- Maintain remission:
- Best to use treatment that has been working
- unless on Methotrexate → not safe!
- all other IBD meds are Class B
- Steroids are okay
- Best to use treatment that has been working
What adverse effects are possible with TNF-α Inhibitors?
- Infections
- Mycobacterial
- Hep B
- Granulomatous infections
- Demyelinating disease
- Heart failure
- Pulmonary fibrosis
- Hepatotoxicity
- Malignancy
- Lymphoma
- Solid tumors
- Skin cancer
- Induction of autoimmunity
Is prednisone a maintainence therapy for IBD?
NO
What are the indications for surgery in Ulcerative Colitis?
- Absolute
- Cancer or dysplasia
- Unresponsive acute disease
- Perforation
- Exsanguinating hemorrhage
- Relative
- Chronic intractability
- Steroid dependency
- Growth retardation
- Systemic complications
What are the indications for surgery in Crohn’s Disease?
- Absolute:
- Free perforation
- Massive hemorrhage
- Cancer or dysplasia
- Chronic high grade obstruction
- Relative:
- Intractability
- Complex fistula and abscesses
- Perianal complications
- Growth retardation
